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Appendix B - Interview Guides

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State Program Manager Interview Guide

I'd like to start by asking some background questions about you.

Would you tell me a bit about yourself, your current position, and other work you've done with STD prevention?

Next, I'd like to ask you some general questions about the people or groups of people who you think are at the greatest risk for syphilis in [state, city or county].

Who do you think is at the greatest risk for syphilis in (STATE)? Why?[PROBE FOR AGE GROUPS, DIFFERENCES BETWEEN MEN AND WOMEN, PEOPLE IN CERTAIN RACIAL AND ETHNIC GROUPS]

Do you think that people who live in certain areas are at greater risk? Which areas and why? [PROBE FOR URBAN/RURAL DIFFERENCES]

Have you noticed any changes in the groups of people infected with syphilis in (STATE)? Since when? What are the changes?

The Centers for Disease Control uses the term "core transmitters" to describe a group of people who are at the greatest risk for syphilis and are also likely to transmit it to other people. One of the main objectives of our research is learn more about characteristics of core transmitters, the people who you think are at the greatest risk of syphilis, in (STATE).

Is that also a term you use?[IF NO] Do you think that such a group exists? [Skip question 6][IF YES] Do you use any particular term to describe them? What is it?

You mentioned that people who live in (areas mentioned previously) may be at greater risk of developing syphilis. Can you tell me more about those areas?

I'm also interested in where people in this area get together, what types of events do they get together for, as well as formal and informal social groups that exist in the area.

I'd like to ask you a little bit about how patterns of STD infection in (STATE) reflect patterns that have been reported elsewhere in the professional literature.

For example, a relationship between syphilis and substance abuse has been suggested. In your view, is there an association between syphilis and substance abuse in [STATE]? Why do you think this is so?

A relationship between commercial sex work or prostitution and syphilis has also been reported. In your view, is prostitution associated with syphilis in [STATE]? Why do you think this is so?

In your view, are people at the greatest risk for syphilis also at risk for HIV and other sexually transmitted disease? [IF YES], How does this affect the kind of outreach prevention or control efforts your target to this population?

What other health care facilities, aside from the public STD clinic, do people at the greatest risk for syphilis use? What is your sense of how accessible these health care services are to people at the greatest risk?

11a. Are these health care facilities able to diagnose and treat syphilis adequately?

11b. Do they provide counseling services?

11c. What is the relationship between the state STD program and these facilities? Do they notify the state of new cases? [PROBE FOR HOW CLOSELY FACILITIES FOLLOW REPORTING REQUIREMENTS]

Next, I'd like to learn more about the organizations in (STATE) that provide services to people at the greatest risk for syphilis. Specifically, I'd like to know what types of organizations exist and what types of services do they provide. I'm interested in private as well as public organizations.

Do you think that syphilis is perceived as a public health problem in the (STATE)? By public health officials? By health care providers? By community leaders?

Can we get a copy of the official public health policies and procedures for syphilis control in (STATE)? [DO NOT ASK IF INFORMATION WAS OBTAINED PRIOR TO THE INTERVIEW]

Have any new programs for STD prevention been initiated in the past three years? Five years? Please describe.[PROBE FOR COMMUNITY OUTREACH, LIAISON WITH PRIVATE AND COMMUNITY-BASED PROVIDERS, TARGETING TO SPECIFIC GROUPS OF PEOPLE.]

Are these programs integrated with any other prevention programs in the [state, city, county]?

In your view, to what extent are organizations in this area working together to prevent syphilis?[PROBE FOR INVOLVEMENT BY CHURCHES, SCHOOLS, CRIMINAL JUSTICE, PUBLIC HEALTH AND OTHER SOURCES OF HEALTH CARE]

Before we finish, would you please describe what your ideal syphilis prevention and control strategy would be?

17a. Is there any community, organization or group of organizations that uses this strategy? Can you tell me more about them?

17b. Do you think that people in the community would be open to this type of strategy? Why or why not?

17c. What barriers prevent implementation of this strategy?

Have there been any changes in funding and other resources for STD prevention and control in the past few years?

18a. Were any resources targeted specifically to syphilis prevention and control?

18b. Were there any other effects of the funding changes on syphilis prevention and control?

That's all the questions I [we] have for today. Thank you for taking the time to answer my [our] questions about syphilis prevention in your area. Do you have any questions for me [us]? Is there anything else you would like to add that we didn't ask about during the interview? [RECORD BELOW] If we have any other questions, would it be okay for us to get back in touch with your offices? Thanks again.

STD Program Staff Interview Guide

I'd like to start by asking some background questions about you.

Would you tell me a bit about your current position? Have you done any other work done with STD prevention? [PROBE FOR PAST POSITIONS, VOLUNTEER, HIV-RELATED]

1a. What proportion of your time is spent in the field? and what proportion in the clinic?

Next, I'd like to ask you some general questions about the people or groups of people who you think are at the greatest risk for syphilis in [state, city or county].

Who do you think is at the greatest risk for syphilis in [state, city, county]? Why? [PROBE FOR AGE GROUPS, DIFFERENCES BETWEEN MEN AND WOMEN, PEOPLE IN CERTAIN RACIAL AND ETHNIC GROUPS]

Do you think that people who live in certain areas are at greater risk? Which areas and why? [PROBE FOR URBAN/RURAL DIFFERENCES] [If no, skip question 4]

You mentioned that people who live in (areas mentioned previously) may be at greater risk. Can you tell me more about those areas?

I'm also interested in where people in this area get together, what types of events do they get together for, as well as formal and informal social groups that exist in the area.

Have you noticed any changes in the groups of people infected with syphilis in [state, city, county]? Since when? What are the changes?

The Centers for Disease Control uses the term "core transmitters" to describe a group of people who are at the greatest risk for syphilis and are also likely to transmit it to other people. One of the main objectives of our research is learn more about characteristics of core transmitters, the people who you think are at the greatest risk of syphilis, in [state, city, county].

Is that also a term you use?[IF NO] Do you think that such a group exists?[IF YES] Do you use any particular term to describe them? What is it?

I'd like to ask you a little bit about how patterns of STD infection in [state, city, county] reflect patterns that have been reported elsewhere in the professional literature.

For example, a relationship between syphilis and substance abuse has been suggested. In your view, is there an association between syphilis and substance abuse in [state, city, county]? In the areas you mentioned previously? Why do you think this is so?

A relationship between commercial sex work or prostitution and syphilis has also been reported. In your view, is prostitution associated with syphilis in [state, city, county]? Why do you think this is so?

In your view, are people at the greatest risk for syphilis also at risk for HIV and other sexually transmitted disease?[IF YES] How is this reflected in prevention activities? counseling activities? outreach activities?

What proportion of the client population that you see would you characterize as "repeaters" [PEOPLE WHO RETURN WITH AN STD SOON AFTER BEING TREATED FOR THE LAST ONE]? Of those, what proportion would you say have syphilis?

11a. What have you found to be the most effective methods for preventing so-called repeaters from becoming re-infected? What are some of the barriers to preventing repeated infection?

What is the average number of contacts per syphilis patient? Is this different than it is for other STDs? How?

I'd like to ask some questions about the impact of STD care and health care on the prevalence of syphilis.

To begin with, do you ever receive complaints from patients about the treatment and services available at this clinic? What complaints do you hear most often? [PROBE FOR HOURS, LOCATION, STAFF] [IF RESPONDENT IS NOT ASSOCIATED WITH A CLINIC] At the publicly funded STD clinic in this county.

Do patients complain about access to other health care services? Please give examples.

In your opinion, are there adequate services for STD patients in this county? Why or why not?

Next, I'd like to talk about syphilis or STD prevention programs in this community.

In your view, to what extent are organizations in this area working together to prevent syphilis?[PROBE FOR INVOLVEMENT BY CHURCHES, SCHOOLS, CRIMINAL JUSTICE, PUBLIC HEALTH AND OTHER SOURCES OF HEALTH CARE]

16a. What other community groups have you worked with? What have you done with them? [PROBE FOR INITIAL CONTACT]

What do you think is the best way of getting out messages to prevent STDs? Does that happen here? Please describe.

What do you think are some of the barriers to getting out effective prevention messages? What are some of the things that make it easier to get out prevention messages in this community?

Are there any populations within the community that are particularly difficult to reach out to? Why?

19a. What programs or interventions have you tried with these populations? How did they go? [PROBE FOR CONTENT]

Are there particular members of hard-to-reach groups who form a bridge with the community at large? How are they accessed? Are these members seen as leaders by the hard-to-reach group?

Before we finish, I'd like to know what you think an ideal syphilis prevention and control strategy would be.

21a. Is there any community, organization or group of organizations that uses this strategy? Can you tell me more about them?

21b. Do you think that people in the community would be open to this type of strategy? Why or why not?

21c. What barriers prevent implementation of this strategy?

That's all the questions I [we] have for today. Thank you for taking the time to answer my [our] questions about syphilis prevention in your area. Do you have any questions for me [us]? Is there anything else you would like to add that we didn't ask about during the interview? [RECORD BELOW] If we have any other questions, would it be okay for us to get back in touch with your offices? Thanks again.

STD Clinic Staff and Health Care Provider Interview Guide

I'd like to start by asking some background questions about you.

Would you tell me a bit about, your current position? Does this include STD prevention, counseling and care? Have you done any (other) work with STD prevention? [PROBE FOR PAID OR VOLUNTEER, HIV]

Next, I'd like to ask you questions about your experience providing medical care to people at risk for STDs.

What services are most frequently sought at this clinic?

Do patients need to have appointments to be seen here? Always, sometimes or never?[IF SOMETIMES] Under what circumstances?

3a. Has this always been the policy? What effect do you think this policy has on clinicians and patients?

What proportion of the client population that you see would you characterize as "repeaters" [PEOPLE WHO RETURN WITH AN STD SOON AFTER BEING TREATED FOR THE LAST ONE]? Of those, what proportion would you say have syphilis?

4a. What have you found to be the most effective methods for preventing repeaters from becoming re-infected? What are some of the barriers to preventing repeated infection?

When you diagnose a patient with syphilis, how do you report the diagnosis to the state or county? [PROBE FOR FOLLOW-UP PROCEDURES]

Now I have a few questions about health care in general in this community.

What do you see as the most pressing health care need for members of this community?

Is there a sufficient number of health care providers in this county? Are their hours accessible to most people?

7a. Do different sectors of the community frequent different health care providers? Who goes where?

Is there any group which you believe does not get adequate health care? Who? Why?

8a. What are some of the things that make it more difficult for certain groups of people to obtain health care than others?

Do you think there are particular barriers for patients with STDs? With syphilis in particular?

I'd like to ask some questions about the impact of STD care and health care on the prevalence of syphilis.

To begin with, do you ever receive complaints from patients about the treatment and services available at this clinic? What complaints do you hear most often? [PROBE FOR HOURS, LOCATION, STAFF]

Do patients complain about access to other health care services? Please give examples.

In your opinion, are there adequate services for STD patients in this [state, city, county]? Why or why not?

Do you know of other STD diagnosis and treatment services in this community? Do these facilities provide services to the same population as this facility? If different, in what ways are they different?

Next, I'd like to ask you some general questions about the people or groups of people who you think are at the greatest risk for syphilis in [state, city or county].

Do you think that syphilis is a problem for any people in this community?[IF RESPONDENT ANSWER "NO", SKIP TO LAST PAGE AND READ THE FINAL BLURB]

Who do you think is at the greatest risk for syphilis in [state, city, county]? Why?[PROBE FOR AGE GROUPS, DIFFERENCES BETWEEN MEN AND WOMEN, PEOPLE IN CERTAIN RACIAL AND ETHNIC GROUPS]

Do you think that people who live in certain areas are at greater risk? Which areas and why? [PROBE FOR URBAN/RURAL DIFFERENCES]

Have you noticed any changes in the groups of people infected with syphilis in [state, city, county]? Since when? What are the changes?

I'd like to ask you a little bit about how patterns of STD infection in [state, city, county] reflect patterns that have been reported elsewhere in the professional literature.

For example, many people report a relationship between syphilis and substance abuse. In your view, is there a relationship between substance abuse and syphilis in [state, city, county]? In the areas you mentioned previously? Why do you think this is so? [PROBE FOR TYPES OF SUBSTANCES]

People report a relationship between commercial sex work or prostitution and syphilis. In your view, is prostitution associated with syphilis in [state, city, county]? Why do you think this is so?

In your view, are people at the greatest risk for syphilis also at risk for HIV and other sexually transmitted disease? Why or why not?

Next, I'd like to talk about syphilis or STD prevention programs in this community.

In your view, to what extent are organizations in this area working together to prevent syphilis?[PROBE for involvement by churches, schools, criminal justice, public health and other sources of health care]

21a. Have you worked with other community groups or STD clinics? What have you done?

What do you think is the best way of getting out messages to prevent STDs? Does that happen here? Please describe.

What do you think are some of the barriers to getting out effective prevention messages? What are some of the things that make it easier to get out prevention messages in this community?

Are there any populations within the community that are particularly difficult to reach out to? Why?

24a. What programs or interventions have you tried with these populations? How did they go? [PROBE FOR CONTENT]

Are there particular members of hard-to-reach groups who form a bridge with the community at large? How are they accessed? Are these members seen as leaders by the hard-to-reach group?

Before we finish, I'd like to know what you feel is an ideal syphilis prevention and control strategy would be.

26a. Is there any community, organization or group of organizations that uses this strategy? Can you tell me more about them?

26b. Do you think that people in the community would be open to this type of strategy? Why or why not?

26c. What barriers prevent implementation of this strategy?

That's all the questions I [we] have for today. Thank you for taking the time to answer my [our] questions about syphilis prevention in your area. Do you have any questions for me [us]? Is there anything else you would like to add that we didn't ask about during the interview? [RECORD BELOW] If we have any other questions, would it be okay for us to get back in touch with your offices? Thanks again.

Community Leaders Interview Guide

I'd like to start by asking some background questions about you.

Would you tell me about your current position? Have you done any work in STD prevention, either here or as a volunteer, or in a previous position? [DOES THIS INCLUDE HIV? IS THIS ONLY WITH HIV?]

Now I have a few questions about health care in general in this community.

What do you see as the most pressing health care need for members of this community?

Is there a sufficient number of health care providers in this county? Are their hours accessible to most people?

3a. Do different sectors of the community frequent different health care providers? Who goes where?

Is there any group which you believe does not get adequate health care? Who? Why?

4a. What are some of the things that make it more difficult for certain groups of people to obtain health care than others?

Do you think there are particular barriers for patients with STDs? With syphilis in particular?

Do you think that sexually transmitted disease is a problem for any people in this community? [DOES THIS INCLUDE HIV? IS THIS ONLY WITH HIV?][IF RESPONDENT ANSWER "NO", PLEASE ASK QUESTIONS 17, 18 AND 21 TO THE END]

Next, I'd like to ask you some general questions about the people or groups of people who you think are at the greatest risk for STDs like syphilis in [state, city or county].

Who do you think is at the greatest risk for STDs like syphilis in [state, city, county]? Why? [PROBE FOR AGE GROUPS, DIFFERENCES BETWEEN MEN AND WOMEN, PEOPLE IN CERTAIN RACIAL AND ETHNIC GROUPS]

Do you think that people who live in certain areas are at greater risk? Which areas and why? [PROBE FOR URBAN/RURAL DIFFERENCES]

Where do people in your locality get together for formal social activities? Informal social activities? [PROBE FOR DIFFERENCES BY AGE, GENDER AND SEX]

I'd like to ask you a little bit about how patterns of STD infection in [state, city, county] reflect patterns that have been reported elsewhere in the professional literature.

For example, there are reports of an association between STDs like syphilis and substance abuse. In your view, is there an association between syphilis and substance abuse in your community? Why do you think so?

Also, a relationship between commercial sex work or prostitution and syphilis has been reported. In your view, is there a relationship between syphilis and prostitution in your community? Why do you think this is so?

In your view, are people at the greatest risk for syphilis also at risk for HIV and other sexually transmitted disease? [IF YES], Do your know of any programs that address this issues? Which ones?

Where do you think people at the greatest risk for STDs like syphilis go to get health care? What is your sense of how accessible these health care services are to the people at greatest risk?

Do you think there is a difference in how men and women seek health care?

Next, I'd like to talk about STD prevention programs in this community.

Do you think there should be special programs to prevent STDs like syphilis? Why or why not?

Are any of your agency's programs concerned with the prevention of STD in general or syphilis in particular? Please describe them.

16a. Have you worked with any other community groups on these kinds of programs? What other community groups do you work with? Tell us about some of the things you do together.

16b. Have you ever worked with the public STD program on a prevention or outreach program? How did that happen? [PROBE FOR WHO MADE THE INITIAL APPROACH - STD STAFF OR CBO] What was the content of the program? What was its effect?

What do you think is the best way of getting out messages to prevent STDs? Does that happen here? Please describe.

What do you think are some of the barriers to getting out effective prevention messages? What are some of the things that make it easier to get out prevention messages in this community?

Are there any populations within the community that are particularly difficult to reach out to? Why?

19a. What programs or interventions have you tried with these populations? How did they go?

19b. What was the content of the program? What effect do you think it had?

Are there particular members of hard-to-reach groups who form a bridge with the community at large? How are they accessed? Are these members seen as leaders by the hard-to-reach group?

Do you think that organizations in this area are working together to prevent STDs like syphilis? To what extent do the various sectors work together including churches, schools, criminal justice, public health and other sources of health care?

Before we finish, could you describe what your ideal syphilis prevention and control strategy would be? [IF RESPONDENT HAS DIFFICULTY WITH THIS QUESTION, RE-PHRASE AS "IDEAL STD PREVENTION AND CONTROL ..."]

22a. Is there any community, organization or group of organizations that uses this strategy? Can you tell me more about them?

22b. What barriers prevent implementation of this strategy?

22c. Do you think that people in the community would be open to this type of strategy? Why or why not?

That's all the questions I [we] have for today. Thank you for taking the time to answer my [our] questions about STDs like syphilis prevention in your area. Do you have any questions for me [us]? Is there anything else you would like to add that we didn't ask about during the interview? [RECORD BELOW] If we have any other questions, would it be okay for us to get back in touch with your offices? Thanks again.

Local Researcher Interview Guide

I'd like to start by asking some background questions about you.

Would you tell me about your current position? How did you come to this position? (Training, experience, expertise). What work do you do related to STDs? [Depending on type of work, probe for more details of work relevant to syphilis]

What do you see as the most pressing health care need for members of this community?

Are there a sufficient number of health care providers in this [Location]? Are these providers accessible to most people? [Probe for accessibility of hours, location, services, payment].

3a. Do different sectors of the community frequent different health care providers? Who goes where?

Is there any group which you believe does not get adequate health care? Who? Why?

4a. What are some of the things that make it more difficult for certain groups of people to obtain health care than others?

Do you think that sexually transmitted disease is a problem for any people in this community? [DOES THIS INCLUDE HIV? IS THIS ONLY WITH HIV?]

The Centers for Disease Control uses the term "core transmitters" to describe a group of people who are at the greatest risk for getting and transmitting syphilis. One of the main objectives of our research is to learn more about the characteristics of core transmitters.

Is core transmitter a term that you use?[If no] What term do you use to describe that group?

Next, I'd like to ask you some general questions about the people or groups of people who you think are at the greatest risk for STDs like syphilis in [state, city or county].

Who do you think is at the greatest risk for syphilis in [state, city, county]? Why? [PROBE FOR AGE GROUPS, DIFFERENCES BETWEEN MEN AND WOMEN, PEOPLE IN CERTAIN RACIAL AND ETHNIC GROUPS, PARTICULAR BEHAVIORS].

There are reports of an association between STDs like syphilis and substance abuse. In your view, is there an association between syphilis and substance abuse in [Location]? Why do you think this is so?

A relationship between commercial sex work or prostitution and syphilis has alsobeen reported. In your view, is prostitution and syphilis associated in [Location]? Why do you think this is so?

Do you think that people who live in certain areas are at greater risk? Which areas and why? [PROBE FOR URBAN/RURAL DIFFERENCES]. [If necessary], Can you tell me more about those areas?

Have you noticed any changes in the groups of people infected with syphilis in (Location)? Since when? What are the changes?

In your view, are people at the greatest risk for syphilis also at risk for HIV and other sexually transmitted disease? [IF YES], How does this affect the kind of outreach prevention or control efforts to target this population?

Where do you think people at the greatest risk for STDs like syphilis go to get health care? What is your sense of how accessible and effective these health care services are for the people at greatest risk?

Do you think there is a difference in how men and women seek health care?

Next, I'd like to talk about STD prevention programs in this community.

Do you think there should be special programs to prevent STDs like syphilis? Why or why not?

Are any of the projects that you work on concerned with the prevention of STD in general or syphilis in particular? Please describe them.

16a. Have you worked with any other community groups on these kinds of programs? What other community groups do you work with? Tell us about some of the things you do together.

16b. Have you ever worked with the public STD program on a prevention or outreach program? How did that happen? [PROBE FOR WHO MADE THE INITIAL APPROACH - STD STAFF OR CBO] What was the content of the program? What was its effect?

What do you think is the best way of getting out messages to prevent STDs? Does that happen here? Please describe.

What do you think are some of the barriers to getting out effective prevention messages? What are some of the things that make it easier to get out prevention messages in this community?

Are there any populations within the community that are particularly difficult to reach out to? Why?

19a. What programs or interventions have you tried with these populations? How did they go?

19b. What was the content of the program? What effect do you think it had?

Are there particular members of hard-to-reach groups who form a bridge with the community at large? How are they accessed? Are these members seen as leaders by the hard-to-reach group?

Do you think that organizations in this area are working together to prevent STDs like syphilis? To what extent do the various sectors work together including churches, schools, criminal justice, public health and other sources of health care?

Before we finish, could you describe what your ideal syphilis prevention and control strategy would be? [IF RESPONDENT HAS DIFFICULTY WITH THIS QUESTION, RE-PHRASE AS "IDEAL STD PREVENTION AND CONTROL ..."]

22a. Is there any community, organization or group of organizations that uses this strategy? Can you tell me more about them?

22b. What barriers prevent implementation of this strategy?

22c. Do you think that people in the community would be open to this type of strategy? Why or why not?

That's all the questions I [we] have for today. Thank you for taking the time to answer my [our] questions. Do you have any questions for me [us]? Is there anything else you would like to add that we didn't ask about during the interview? [RECORD BELOW] If we have any other questions, would it be okay for us to get back in touch with you? Thanks again.